Dr. Nancy T. Akins Foundation Academy Certified School Psychologist

Transcription

1 Dr. Nancy T. Akins Foundation Academy Certified School Psychologist Testing Office: Mailing of Testing Forms: 2234 Winter Woods Blvd Hoffner Ave. #264 Winter Park, FL Orlando, FL Student Background Information Student s name: Date: Birthdate: Father s name: Age: Sex: Grade: _ Teacher: Work phone: Cell phone: Mother s name: Work phone: Cell phone: Home address: Home phone: Referred by: (Street) (City) (Zip Code) Reason: A. FAMILY HISTORY: This child is: biological adopted foster This child lives with: birth father birth mother stepfather stepmother legal guardian Since the child s birth, has there been any major trauma? Please check all that apply Reaction of child: Death in family Separation Divorce Remarriage of mother Remarriage of father Other major trauma Foundation Academy School Office Tilden Rd. Winter Garden, FL (407)

2 Siblings in the home: Name Birthdate Grade Present School Do any members of your family have a history of learning difficulties? yes no If yes, please explain: Describe your child s relationship with each member of the family. B. MEDICAL HISTORY: Child was: full term premature State any complications which occurred during pregnancy (ex: toxemia, diabetes, etc.) State any complications which your child had immediately after birth (ex: difficulty breathing, blue color, etc.) recent physical exam recent eye exam recent hearing exam speech/language evaluation other medical or neurological exams : Check all that apply: allergies needs glasses history of high fevers asthma wears glasses seizures hearing difficulties major injury history of ear infections as a child

3 Explain any items checked above: Is your child presently on medication? yes no If yes, please identify type, dosage and explain any noticeable behavioral effects of the medication. C. DEVELOPMENTAL HISTORY: Problems in infancy or childhood with: crawling talking walking/running eating colic sleeping bedwetting slower to develop Explain any items checked above: Your child is: right-handed left-handed ambidextrous child is unsure Child s interests and skill areas: D. EDUCATION: Please list all schools your child has attended (preschool to present). School Grades Reason for change: State the child s best and worst subject: Best Worst Please check and explain any of the following that apply to your child. repeated grade(s): had difficulty adjusting: received tutoring: began kindergarten late:

4 participated in other supplemental services: enrolled in special classes: diagnosed with ADD or ADHD: receives/received physical/occupational therapy: receives/received speech or language therapy: had educational diagnostic testing: (If yes, a copy of this report is required.) Additional comments or information regarding child s schooling: E. ACADEMIC HISTORY: Check where applicable. Use for emphasis. Reading Silent reading comprehension Vocabulary (word meanings) Oral reading accuracy Oral reading fluency (speed) Oral reading comprehension Strength Average Frustration/weakness Spelling Weekly tests Spelling in sentences Written Language Generation of ideas Organization of thoughts into sentences Construction of cohesive paragraphs Fluency in the writing process Math Computation Story problems Math facts (automatic recall)

5 Strength Average Frustration/weakness Handwriting Neatness Speed of writing too fast too slow F. SOCIAL/BEHAVIOR HISTORY: Check the following characteristics of your child with 5 being Very Frequently and 1 being Almost Never is distractible procrastinates is moody from day to day is withdrawn is difficult to manage at home is unlikely to share his/her problems is overly sensitive over-reacts to problems or changes enjoys school complains about school prefers to play with much younger children prefers to play with much older children relates well with adults seems to lack common-sense is independent is dependent is aggressive is passive is easily frustrated is overly fearful is confident Is there any additional information you would like to share prior to testing? If so, please share: